Timely documentation in nursing is incredibly important as it provides the backbone for future treatments. Records of high quality make it easier for doctors and nurses to identify any new or old problems, potentially making life-saving decisions. The files can be useful in case of readmissions and new diagnoses and in the handovers of the shifts to the next nurse. If the records are kept up to a standard, the transition is smooth, and communication is efficient. Furthermore, there is a legal consideration that is related to record-keeping. If the patient suffers from an inadequate level of care or has a complaint, proper records make the proper procedures easier.
However, there are some obstacles to timely documentation by the nursing staff, including the lack of time and poor communication between different members of staff. Nurses often must endure incredibly long hours at work, which means that it can be difficult to prioritize record-keeping at the end of a long day. If the hospital is busy with patients, this might also leave little time for timely documentation since the nurses might prioritize attending to the patients. Furthermore, some nurses might regard these records as a mere formality and hence not value their significance, not making sufficient effort to fill them out on time.
Any combination of these factors might lead to the records being incomplete when they are passed on to the next nurse on shift. This, then, can make it very difficult for them to chase down the information they need for the documentation. Overall, although these and other barriers are avoidable, they are difficult to overcome, especially for new or inexperienced members of staff.
When I am documenting, I tend to be quite meticulous and label each entry as clearly as I can – including the date, time, and my signed name. Furthermore, I use a pen instead of a pencil to ensure better preservation of the records, and I have relatively clear handwriting to make it legible for both myself and other nurses. I am quite persuasive in my pleading to get the patients to sign the forms since, at times, it can be difficult to convince them to follow the formalities. Lastly, I make sure to include a checklist and notes for the next personnel on shift to make their work easier.
However, there are some things that are still a little challenging for me regarding documentation. Firstly, although I always try to note down as much useful information about the patient as possible, I do not always use standardized forms. Therefore, they can occasionally get a little confusing or more difficult to find. Furthermore, sometimes I find it quite difficult to filter out irrelevant information, which results in my notes being too extensive. However, I am working on these weaknesses, as well as on identifying any other possible issues I might have.